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High Acuity > Neuro > Flashcards

Neuro Flashcards

1
Q

Monro-Kellie Doctrine

A

Skull = barrier

  1. CSF absorption/production/displacement to the spinal cord
  2. Cerebral Vessels
    Vasoconstriction/dilation
  3. Brain Tissue
    expansion into dura/compression of the tissue

ICP increases related to the displacement of lesions (head injury, cerebral edema, tumor, encephalitis), herniation, ischemia, brain death

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2
Q

Cerebral Perfusion Pressure

A

CPP = 60-100
<60 = ischemia/neuron death
>100 = increased and breakthrough hypoperfusion

CPP = MAP-ICP
MAP is the only thing you can control

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3
Q

Causes of Increased ICP

A

MASS hematoma, contusion, abscess, tumor

CEREBRAL EDEMA (increased fluid in extravascular space) tumor, hydrocephalus, head injury, inflammation, meningitis, encephalopathies, vascular insult (stroke, anoxic episodes, cardiac arrest)

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4
Q

Clinical Manifestations of Increased ICP

A

CHANGES IN LOC impaired cerebral flow (GCS <8 intubate)

CHANGES IN VS
temperature (hypothalamus)
Cushing’s Triad

OCULAR SIGNS Unilateral, fixed, dilated pupil = medical emergency
Sluggish pupils, no response to light, does not move up/laterally, ptosis

DECREASE MOTOR FUNCTION Hemiparesis/hemiplegia (1-sided weakness/paralysis)
Cannot withdraw from painful stimuli
Posturing = decorticate/decerebrate

H/A

VOMITING - projectile and unexpected
Sometimes can be accompanied by nausea

SEIZURES

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5
Q

Cerebral Perfusion Pressure (CPP)

A

Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

Normal CPP = 60-100 mmHg
Normal MAP = 70-90 mmHg
Can control the pressures
Normal ICP = 5 -15 mmHg

ICP > MAP brain cannot be perfused

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6
Q

Complications of Increased ICP

A

HERNIATION related to displacement which can lead to brainstem death

Pressure on the medulla (controls breathing)
Sudden changes of neurological status and VS, pupillary changes

Cushing’s Triad

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7
Q

Cushing’s Triad

A

Widen pulse pressure (increased BP)
Low HR
Irregular Respirations (Cheyne-Stokes)

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8
Q

DX Studies

A

LABS
ABG - PaO2/PaCO2
CBC - H/H, plts
Coag Profile
Chem panel - Na+
Serum and Urine Osmoalality
Drug/Tox Screen

IMAGING
CT and MRI for any presence of lesions
EEG
Transcranial Doppler - blood flow of the brain

PROCEDURES
ICP measurements

NO LUMBSR PUNCTURES Suddenly release P leading to brain herniation

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9
Q

Ventriculostomy/External Ventricular Drain (EVD) Functions

A

Measure ICP - Stroke, hemorrhage, tumors, infection, TBIs

CSF Drainage - dx/intervention
sample, monitor, and can give meds

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10
Q

Leveling the Transducer

A

Tragus of the ear
Foramen of Monro

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11
Q

EVD Complication

A

Risk of Infection with prolonged use

Routine assessment (insertion site), aseptic technique, monitor CSF for color/clarity (cloudy = infection)

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12
Q

Drug Therapy

A

Mannitol = Osmotic Diuretic
Decreased ICP and decreased fluid total volume and moving it from tissues into vasculature
Monitor F&E

Hypertonic Saline = Higher sodium pulls water out of tissue

Corticosteroids = Lower cerebral edema

Prophylactic Anti-Seizure Meds (dantrolene, levetiracetam) - prevent seizures that increase ICP

Antipyretics - Tx fever and pain
Shivering increases ICP

Sedatives/Pain Management NO strong opioids (fentanyl/morphine) because it alters neuro assessment
Paralytics decrease metabolic demands

BP MANAGEMENT
Vasoactive drugs (epi/norepi/vasopressin/dopamine)
IVF to increase blood volume
MAP > 90 CPP >70

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13
Q

Nursing Care Increased ICP Goals

A

Maintain patent airway
Normal F&E balance
ICP w/in normal limits
Prevent complications from immobility and low LOC

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14
Q

Nursing Interventions

A

MAINTAIN RESPIRATORY FUNCTION avoid hypoxia and hypercapnia (increases ICP and lowers CPP)

SEDATION Paralytics and Analgesic
Pain, anxiety, fear, nursing care can increase ICP

F&E BALANCE, ADEQUATE NUTRITION
I&O, Fluids, Serum Electrolytes (DI and SIADH)
Intural Nutrition

MONITORING/MAINTAIN ICP Don’t scare the patient or stimulate the patient, needed straining
Control body temperature
Monitor environment, neutral body positioning, C-collar stabilization, HOB 30

PROTECTION FROM INJURY RELATED TO IMMOBILITY
VTE Prophylaxis - SCDs, lovenox (24-48 hours)
Neutral body positioning (C_Collar if needed) tQ2

PSYCHOLOGIC CONSIDERATIONS -anxious
Consult Social Work/Champlain

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15
Q

Brain Death

A

Coma, responsiveness, absence of brainstem reflexes, apnea (no air on their own)

Irreversible cessation of all brain activity
Confirmed by MRI, bedside assessments, and apnea exam
Emotional reassurance with Chaplin consult
Organ Donation

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16
Q

Head injury

A

Serious = TBI

Causes - falls, MVCs, assaults, firearms

Types = Scalp lacerations, skull fractures, head traumas

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17
Q

Skull Fractures

A

TYPES
linear, depressed
simple, comminuted, compound
Closed/open

CLINICAL MANIFESTATIONS
CN deficits
Postauricular bruising (Battle Sign)
Periorbital bruising (Raccoon Eyes)
Rhinorrhea and otorrhea (+) CSF r/t tear in dura (Halo, (+) glucose)

COMPLICATIONS
Intracranial infections, hematoma. meningeal and brain tissue damage

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18
Q

Head Trauma

A

DIFFUSE - Concussion, diffuse axonal injury (not limited to 1 area)
MVC (rapid speeding and slow down causing white matter to shear)
Nursing care = frequent assessments and pain management

FOCAL - Lacerations and Contusion
Coup Contrecoup = site and directly opposite of the brain

COMPLICATIONS
Cerebral hematomas (epidural and subdural)
Intracerebral Hematomas (inside brain tissue)

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19
Q

Assessment of Head Injury

A

Through baseline assessment - other assessments based on this

GCS/EMV - LOC/mental alertness/pupils
VS - respiratory pattern changes suggest deterioration
Monitor ICP

CSF leak, vomiting, bowel, bladder inc., battle sign, periorbital edema

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20
Q

TX of Head Injury

A

Lower ICP/Minimize interventions that cause an increase in ICP
Maintain CPP
Stabilize VS
Acetaminophen for pain control (NO NARCOTICS because it alters/impact LOC)
AVOID NGT placement (contraindicated with skull fractures) Oral insertion ok

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21
Q

Cranial Surgery

A

Increased risk of infection and high ICP
Monitor and Prevent increased ICP

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22
Q

Meningitis

A

Bacterial = deadly
Spread via respiratory secretions

Dx = lumbar puncture (WBC, protein, glucose, gram stain, cultures), CBC, coagulation profile, electrolyte panel, plt count, blood cultures, CT, MRI

S/S = Fever, severe h/a, N/V, nuchal rigidity (neck stiff and hard to move), (+) Bradzinski’s sign (severe neck stiffness when hips and knees are flexed) photophobia, decreased LOC, signs of increased ICP, seizures, irritability, petechiae, papilloedema (swollen optic disk)

TX= IV abx, pain control, temp. control
Health promotion = Vaccines

23
Q

SCI Classification

A

Mechanism

Level of Injury
Tetraplegia (T2- L1) - loss of motor/sensory function or extremities
Paraplegia (C1- T1) - muscle function depends on specific segments involved with impairment to arms, trunk, legs, pelvic organs

Degree
Complete
Incomplete

24
Q

Degree of SCI

A

COMPLETE loss all voluntary motor and sensory function below level of injury

INCOMPLETE Preservation of some sensory/motor function below level of injury due to partial damage
Spastic = hyperactive neurons causing exaggerated tendon reflexes and muscle spasms
Flaccid = weakness, loss muscle tone and no reflexes
Cauda Equina

25
Q

S/S of Cauda Equina

A

Urinary retention
fecal incontinence
unilateral/bilateral sciatica
reduced straight leg raise (paresthesia)
saddle anesthesia (groin numbness)

26
Q

Clinical Manifestations

A

Neurogenic Bladder
Thermoregulation
Increased metabolic needs
Peripheral Vascular Problems
Motor and sensory, resp., CV, GI, skin, pain

27
Q

Assessment

A

Neuro checks serially q1hr for 1st 24 hours

Airway/oxygenation (c1-3 = apnea and C4 = poor cough and difficulty breathing)

Bradycardia and Hypotension (above T6 = CV problems)

Decreased/absent bowel sounds, constipation, fecal incontinence (flaccid = constipation spastic = diarrhea)

Skin (warm, dry skin below injury - shock)

Urinary retention/INC.

Sensory Status
Exact point where normal sensation is present

Motor status
Voluntary mvts./Muscle Strength

Reflexes
Hyperactive deep tendon reflexes = complete SCI

28
Q

Spinal Shock

A

AFFECTS ONLY SPINAL CORD
Bleeding, inflammation, tissue damage – mediators + vasoconstriction – ischemia and hypoxemia

Complete Transection = Cannot regain mvt.
Partial Transection = regain mvt. below injury – relieved bleeding and inflammation via steroids

Loss of sensation, DTRs, and Sphincter reflexes below the level of injury

Flaccid paralysis occurs below level of injury

OUT OF SHOCK – Spastic and DTRs recovered

29
Q

DX Spinal Shock

A

MRI = inflammation, infection, edema, or vascular disruptions along with injuries of spinal cord, ligaments, and disks
CT Scan = Visualization of bony structures of spine and ID spinal fx
Angiography = vertebral/cranial arteries w/in cervical spinal column

30
Q

SCI Immediate Nursing Actions

A

Airway Management
Intubate until the inflammation goes away
Decompress Stomach with NGT
IS, help w/ coughing

Spinal Immobilization
Bed Rest
Log-rolling maneuvers
C-Collar until spine stabilized with Sx, traction, or an external device or cleared

Steroid Therapy (methylprednisolone) preventing secondary injury
give w/in 3 hours for 48 hours

Monitor for Autonomic Dysreflexia for SCI above T6

31
Q

Autonomic Dysreflexia

A

Exaggerated SNS response for SCI above T6 below site of injury

BP raises to dangerously high levels

32
Q

Autonomic Dysreflexia Risk Factors

A

Bladder Distention/Spasm
Bowel Impaction
Stimulation of anal reflex
Temperature changes
Tight, irritating clothes, pressure injury
UTI
Decubitus Ulcer
Pain
Sexual activity
Menstruation
Broken Bones

33
Q

Treatment

A

FIND and TX cause
Lower BP
Raise HOB
Loosen binding/restrictive clothing
Check for urinary occlusion/over-distention
Check for impaction and facilitate defecation
Pain meds (avoid opioids as impact LOC and cause constipation)
Infection monitoring
Personal care – bladder and bowel program, ulcer checks

34
Q

Symptoms

A

Severe hypertension due to vasoconstriction
Sweating, flushing
Bradycardia
Piloerection = hair sticking up
Sudden headache
blurred vision
anxiety

35
Q

Impaired Gas Exchange/Ineffective Breathing Patterns

A

SCI C1-2 = Mech. Ventilation r/t loss of phrenic nerve innervation to diaphragm

C3-5 = Vary degrees of diaphragm paralysis and need ventilator support

BELOW C6 = impaired intercostal and abdominal muscle function causing abnormal respiratory reflexes (coughing, sneezing)

36
Q

Impaired Gas Exchange/Ineffective Breathing Patterns Interventions

A

Monitor ABC, physical exam, ventilation, ability to cough and clear secretions and O2

Aggressive Resp. therapy
Supp. O2
Chest PT/IS
Cough and Deep Breathing
Early Ambulation
Assisted coughing devices
Bronchodilators and Mucolytics to mobilize secretions

37
Q

Decreased CO

A

Low BP (orthostatic)
Dysrhythmias
HR < 60 – vagal response – Cardiac Arrest

38
Q

Decreased CO Interventions

A

Monitor VS, CO, CVP
SBP > 90 MAP =85- 95
HOB elevated
Vasopressors PRN

Early detection of bradycardia (above T6) r/t unopposed vagal stimulation
Atropine
Pacemaker
Limit vagal stimulation

39
Q

Impaired Urinary/Bowel

A

URINARY
Depending on level of injury
Neurogenic Bladder = loss of autonomic control of the bladder (cannot sense fullness and do not know when to pee)
Risk for inc., Reflux, renal stones, obstruction, UTI, overdistention

BOWEL
Reflexic or flaccid bowel
Neurogenic Bowel = loss of autonomic control of bowel
Risk for Inc., Constipation, bowel obstruction, Ileus

40
Q

Impaired Urinary/Bowel Interventions

A

URINARY = Maintain infection-free GU
In and Out Cath. = GOLD standard and ensures full emptying of the bladder
FC
Bladder scan
Suprapubic
Imperative cleaning
Bladder spasticity

BOWEL - Establish routine daily bowel care to Avoid severe constipation/inc.
Bowel training via suppository/digital Stimulation (enemas), oral stool softeners (Miralax)
Monitoring diet and fluid intake (increase fiber)
Timing bowel routine with intake to incorporate gastrocolic and anorectal reflexes
Avoid opioids

41
Q

Ineffective Thermoregulation

A

Interruption of SNS (spine and hypothalamus)
Poicalothermia = inability to maintain constant core temperature and assumes temperature of the environment

Hyperthermia r/t loss of sympathetic control of sweat glands below the level of lesion prohibits sweating as temperature rises

Hypothermia r/t unable to maintain at appropriate temperature and requires passive warming devices

42
Q

Ineffective Thermoregulation Interventions

A

Set the room temperature warmer

43
Q

Imbalanced Nutrition

A

HIgh metabolic state BUT get low nutrition due to bowel issues, limited ability to feed themselves, depression

Risk for paralytic ileus (NGT LWS), stress ulcers (PPIs and H2 blockers)

44
Q

Imbalanced Nutrition Interventions

A

Consult Nutrition
Monitor I&O’s, weights
Initiate enternal nutrition early
Swallow eval (risk aspiration)
Monitor serum albumin and prealbumin (nutritional status)
NGT to reduce gastric distention

45
Q

Risk for Thromboembolism

A

Venous Stasis r/t lack of movement and lack of muscle tone

46
Q

Risk for Thromboembolism Interventions

A

Monitor s/s of DVT/PE
SCDs early and LMWH – promote venous return
PT/OT consult or ROM exercises to prevent clots

47
Q

Risk for Infection

A

High thoracic/cervical injury increases risk of pneumonia, UTIs, and decubitus ulcer formations

48
Q

Risk for Infection Interventions

A

S/S of infection
Monitor urine ad sputum color/clarity
Monitor wound beds
Remove FC ASAP
Strict daily perineal care (clean and dry)
Cough, deep breathing, IS
Chest PT/assissted coughing devices to mobilize secretions
Frequent turning – assist mobilizing secretions and prevent wounds

49
Q

Risk for Skin Breakdown

A

Sensory and motor impairment – skin subjected to prolonged periods of pressure
Unable to feel discomfort/pain from pressure
Unable to change positions independently
Moisture exposure from sweating or bladder/bowel inc. – pressure ulcer formation and increases risk for infection

50
Q

Risk for Skin Breakdown Interventions

A

Frequently repositioning, tQ2, log roll
Heel protectors
Speciality beds to provide pressure reduction
Physical assessments of all skin areas
Evaluate for breakdown in unusual places
Remove wrinkles or loose bedding
Maintain body in neutral position
Passive ROM

51
Q

Self Care Deficits Interventions

A

Set Rehab goals
Encourage independence early
Ambulate Early
Bowel and Bladder routines

52
Q

Psychosocial

A

Suddenly experiences immobility and adjustments to social, economic, and personal roles/relationships

53
Q

Psychosocial Interventions

A

Offer open communication for expression of anxieties, fears, anger, sadness, concerns
Allow patient to grieve over the loss of life they expected
Focus on patient’s current abilities
Teach patient and family self-care measures to promote independence
Provide support groups
Psychological support with referrals if needed

High Acuity (7 decks)

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